title: Assessment of Traub formula and ketone bodies in cause of death investigations.
abstract: Diabetes and alcohol abuse may cause severe metabolic disturbances that can be fatal. These may be difficult to diagnose in autopsies based solely on macroscopical and histological findings. In such cases, metabolic markers, such as postmortem glucose and ketone levels, can provide supporting information. Glucose or combined glucose and lactate, the Traub value, is often used to indicate hyperglycemia. The use of the Traub value, however, has been questioned by some, because the lactate levels are known to elevate in postmortem samples also due to other reasons than glycolysis of glucose molecules. Ketoacidosis can be detected by analyzing ketone body levels, especially beta-hydroxybutyric acid (BHB). Acetone is also elevated in severe cases of ketoacidosis. Here, we have evaluated the value of these biomarkers for postmortem determination of the metabolic disturbances. Retrospective data of 980 medico-legal autopsies performed in Finland, where glucose, lactate and ketone bodies were analyzed, was collected. Our findings show that the Traub value indicates hyperglycemia, even when glucose levels are low. For diagnosis, evaluation of complementing markers, e.g. ketone bodies and glycated hemoglobin is needed. Our results show that BHB can be used for screening and diagnosis of ketoacidosis. Acetone alone is not sufficient, since it is elevated only in the most severe cases. We also found that alcohol abuse rarely causes severe ketoacidosis. However, sporadic cases do exist where ketone body levels are extremely high. Despite this, alcoholic ketoacidosis is very rarely diagnosed as the cause of death.
authors.affiliation: Laboratory of Forensic Biology, Department of Forensic Medicine, Hjelt Institute, PO Box 40, FI-00014, University of Helsinki, Finland, terhi.keltanen@helsinki.fi.
authors.forename: Terhi
authors.initials: T
authors.lastname: Keltanen
authors.forename: Antti
authors.initials: A
authors.lastname: Sajantila
authors.forename: Jukka U
authors.initials: JU
authors.lastname: Palo
authors.forename: Teija
authors.initials: T
authors.lastname: Partanen
authors.forename: Tiina
authors.initials: T
authors.lastname: Valonen
authors.forename: Katarina
authors.initials: K
authors.lastname: Lindroos
mesh_terms: D020155:3-Hydroxybutyric Acid / Q000097:blood; D000090:Acetoacetates / Q000097:blood; D000096:Acetone / Q000097:blood; D000437:Alcoholism / Q000097:blood* / Q000473:pathology*; D000465:Algorithms; D001344:Autopsy; D015415:Biomarkers / Q000097:blood; D001786:Blood Glucose / Q000032:analysis*; D002423:Cause of Death; D003920:Diabetes Mellitus / Q000097:blood* / Q000473:pathology*; D016883:Diabetic Ketoacidosis / Q000097:blood* / Q000473:pathology*; D003937:Diagnosis, Differential; D005387:Finland; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D006943:Hyperglycemia / Q000097:blood* / Q000473:pathology*; D007657:Ketone Bodies / Q000097:blood*; D019344:Lactic Acid / Q000097:blood*; D011180:Postmortem Changes; D011237:Predictive Value of Tests
chemical_list: D020155:3-Hydroxybutyric Acid; D000090:Acetoacetates; D000096:Acetone; D015415:Biomarkers; D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007657:Ketone Bodies; D019344:Lactic Acid; C517652:hemoglobin A1c protein, human; C016635:acetoacetic acid